Review: Pelvic nerves - from anatomy and physiology to clinical applications

Abstract

A prerequisite for nerve-sparing pelvic surgery is a thorough understanding of the topographic anatomy of the fine and intricate pelvic nerve networks, and their connections to the central nervous system. Insights into the functions of pelvic nerves will help to interpret disease symptoms correctly and improve treatment. In this article, we review the anatomy and physiology of autonomic pelvic nerves, including their topography and putative functions. The aim is to achieve a better understanding of the mechanisms of pelvic pain and functional disorders, as well as improve their diagnosis and treatment. The information will also serve as a basis for counseling patients with chronic illnesses. A profound understanding of pelvic neuroanatomy will permit complex surgery in the pelvis without relevant nerve injury.

Keywords: chronic pelvic pain; hypogastric nerves; pelvic neuroanatomy; pelvic neurophysiology; pelvis.

Figure 1

Anatomical illustration of the abdominal sympathetic system in an ancient anatomical atlas (Dr Carl Toldt, Berlin and Vienna, 1903).

Figure 2

Schematic diagram of somatic and autonomic pelvic nerves.

Figure 3

Topographic anatomy of the posterior pelvic compartment. Medial view of a right-sided male hemipelvis. The parietal pelvic fascia is removed to visualize the embedded autonomic pelvic nerves. (a) The posterior pelvic compartment is delimited from the urogenital compartment by the rectoprostatic septum (Denonvilliers’ fascia). (b) The rectum is pulled aside to reveal the inferior hypogastric/pelvic plexus, the hypogastric nerve, and the PSN (PSN, from sacral nerve S4). The inferior hypogastric nerve gives rise to rectal nerves and more caudally to internal anal sphincter nerves, as well as the neurovascular bundle (of Walsh) to the prostate [52].

Figure 4

Topographic anatomy of the posterior pelvic compartment. Dorsocranial view of a male pelvis. (a) The rectum and the mesorectum with the superior rectal artery are transected at the rectosigmoid junction (clamp). (b) Dorsolateral mobilization of the mesorectum between the parietal pelvic fascia and the mesorectal fascia along the retrorectal space. Both fasciae are fused by the rectosacral ligament. (c) The parietal pelvic fascia and both ureters are lifted to expose the presacral space behind the presacral fascia. (d) Diaphanoscopy of the parietal pelvic fascia reveals the embedded SHP and both HN [52].

Figure 5

Robotic surgery performed in a female body donor, exposing the sacral nerve roots (yellow) S1–S4, the sacral sympathetic trunk (purple), the hypogastric nerve (orange), and PSN (green).

Figure 6

Anatomical illustration of somatic and autonomic pelvic nerves in a female pelvis (frontal view). Yellow – somatic nerves, orange – sympathetic plexus, purple – sympathetic trunk, green – PSN.